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VERIFICATION OF RESTROOM FACILITY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): Gq }-0 'i�jL4 efg;'e;'� <br /> Address for Vehicle: I Z I I 'S . 11^ Modec'� CA ^1 �✓) <br /> Street Address City <br /> 1) License Plate #: 455 y1 S 9 <br /> 4F�F �_ 4) Year: 20I q <br /> 2) Vehicle Vin #: `ACgpVIR2.L+kH_i020" Make/Model: C-1 C--r <br /> 3) State Decal #: 6) Color: <br /> {VEHICL'E OWNER INFORMATION <br /> Name: LJ in <br /> — ,- - ---- - — -- - f <br /> e' <br /> Address of Owner: A <br /> 5'13 r e an Patbl� <br /> Street ddress City <br /> Mobile food facilities shall be operated within 200 feet of approved and readily available toilet and hand washing <br /> facilities. This is to ensure restroom facilities are available to employees whenever the mobile food facility is <br /> stopped to conduct business (CalCode section 114315). <br /> 1 have access to the restroom facilities at the following business during my business hours and I am parked less <br /> than 200 feet away from the restroom facilities. I will be responsible for maintaining the restroom in a clean and <br /> sanita vcondition. <br /> ijoa2 C bOYKG� r <br /> Signature of Vehicle Operator Date <br /> (RESTROOM INFORMATION <br /> Business Name: lu -Iy ('Or-CLLr <br /> Owner Name: j r1� wr 55 <br /> Site Address: ' C6033 Q Gk- -I <br /> Street Address City <br /> Phone: Zt7 Z6 -S`90 <br /> I, the business owner/operator, can and will provide the necessary restroom facilities for the operators of the <br /> above-mentioned vehicle at my business and I understand that the restroom facilities are subject to <br /> Environmental He th Department inspection. <br /> -e& t "6ko-1 91 <br /> Signature Business o er/Operator Date <br /> EHD 16-017 6 of 6 MFPU APPLICATION <br /> 7/28/2010 <br />